National governments, non-governmental organisations,academics, and civil society need to consider what the appropriate role of the private sector will be in NCD [Non-Communicable Disease] prevention and control.

Although there is now consensus that the tobacco industry’s conflict of interest with public health is irreconcilable, whether the competing interests of the alcohol, food, and drink industries are similarly irreconcilable is debated.

The science of the effect of corporate behaviour on health is an emerging area of public health that needs to be developed substantially; it studies the health risks of transnational corporations and the distribution of the unhealthy commodities that they make and market.

In industrial epidemics, the vectors of spread are not biological agents, but transnational corporations. Unlike infectious disease epidemics, however, these corporate disease vectors implement sophisticated campaigns to undermine public health interventions. To minimise the harmful effects of unhealthy commodity industries on NCD prevention, we call for a substantially scaled up response from governments, public health organisations, and civil society to regulate the harmful activities of these industries.

Ultra-processed products

Ultra-processed products are made from processed substances extracted or refined from whole foods—eg, oils, hydrogenated oils and fats, flours and starches, variants of sugar, and cheap parts or remnants of animal foods—with little or no whole foods. Products include burgers, frozen pizza and pasta dishes, nuggets and sticks, crisps, biscuits, confectionery, cereal bars, carbonated and other sugared drinks, and various snack products. Most are made, advertised, and sold by large or transnational corporations and are very durable, palatable, and ready to consume,which is an enormous commercial advantage over fresh and perishable whole or minimally processed foods. Consequently, their production and consumption is rising quickly worldwide. In the global north—ie, North America and Europe—ultra-processed products have largely replaced food systems and dietary patterns based on fresh and minimally processed food and culinary ingredients that have less fat, sugar, and salt. In the global south —ie, Asia, Africa, and Latin America— ultra-processed products are displacing established dietary patterns, which are more suitable socially and environmentally. Ultra-processed products are typically energy dense; have a high glycaemic load; are low in dietary fibre, micronutrients, and phytochemicals; and are high in unhealthy types of dietary fat, free sugars, and sodium.When consumed in small amounts and with other healthy sources of calories, ultra-processed products are harmless; however, intense palatability (achieved by high content fat, sugar, salt, and cosmetic and other additives), omnipresence, and sophisticated and aggressive marketing strategies (such as reduced price for super-size servings), all make modest consumption of ultra-processed products unlikely and displacement of fresh or minimally processed foods very likely. These factors also make ultra-processed products liable to harm endogenous satiety mechanisms and so promote energy overconsumption and thus obesity.

The consumption of energy-dense ultra-processed foods, unlike low energy foods such as fruits and vegetables, promotes obesity. Similarly, consumption of sugar-sweetened beverages is associated with increased rates of obesity and diabetes,childhood obesity,long-term weight gain, and cardiovascular disease. In addition to the deaths caused by tobacco and alcohol, more than 18 million deaths every year are caused by high blood pressure (9·4 million), high body-mass index (3·4 million), high fasting blood glucose (3·4 million), and high total cholesterol (2·0 million),much of which could be attributed to the consumption of ultraprocessed foods and drinks.

Almost all growth in the foreseeable future in profits from the sale of these unhealthy commodities will be in low-income and middle-income countries. Saturation of markets in high-income countries and the high global average of income that people spend on food (20%) has caused the alcohol and ultra-processed food and drink industries to rapidly penetrate emerging global markets, as the tobacco industry has done. Transnational corporations are major drivers of the acceleration
of the nutrition transition—i.e., from traditional diets of whole or minimally processed foods to highly processed foods and drinks. The substantial growth of ultra-processed products has paralleled and contributed to the increase in obesity, diabetes, and other diet-related chronic diseases,especially in low-income and middle-income countries.

In the USA, the ten largest food companies control more than half of all food sales. Worldwide, this proportion is about 15% and is rising rapidly.

Strategies by industry to undermine effective public health policies and programmes:

Industry documents released because of tobacco and asbestos litigation show how these industries affect public health legislation and avoid regulation with both hard power (ie, building financial and institutional relations) and soft power (ie, influence of culture, ideas, and cognitions of people, advocates, and scientists). There is now evidence to show that the food, drink, and alcohol industries use similar tactics and strategies to the tobacco companies to undermine public health interventions.

The first strategy is to bias research findings. For example, Philip Morris International implemented the Whitecoat project to hire doctors to publish ghostwritten confounder studies purporting to negate links between environmental tobacco smoke and harm. The tobacco companies created quasi-independent organisations to publish biased and partial scientific reports, deny harm, and suppress health information. Similarly, funding from transnational food and beverage corporations biases research. A meta-analysis of research publications showed systematic bias from industry funding, with articles sponsored exclusively by food and drinks companies four-times to eight-times more likely to have conclusions favourable to the financial interests of the sponsoring company than those that were not sponsored by food or drinks companies. The International Center for Alcohol Policies, an organisation established and funded by large global alcohol producers, commissioned reports from scientists that resemble WHO documents. These reports were “incomplete, not subject to traditional peer review, and either supportive of industry positions or emphasizing high levels of disagreement among scientists”

The second strategy is to co-opt policy makers and health professionals. To undermine tobacco control research, the US Tobacco Institute promoted partnerships with scientists. They hired researchers and disseminated health promotion strategies to mislead the public about the harmful effects of smoking. Like the tobacco industry, the food and drink industry develops customers as young as possible, using tactics such as early-childhood health promotion schemes. SAB Miller and the International Center for Alcohol Policies have assisted the Lesotho, Malawi, Uganda, and Botswana Governments to write their national alcohol control policies. The four draft National Alcohol Policy documents were “almost identical in wording and structure and that they are likely to originate from the same source”,and were designed to “serve the industry’s interests at the expense of public health by attempting to enshrine ‘active participation of all levels of the beverage alcohol industry as a key partner in the policy formulation and implementation process’”

The third strategy is to lobby politicians and public officials to oppose public regulation. Tobacco transnationals lobby policymakers and fund campaigns of politicians who support tobacco use. The lobbying power of alcohol and ultra-processed food and drink corporations is also substantial. According to US Senate records, the largest alcohol companies spent $150 million lobbying compared with $40 million for tobacco between 1999 and 2011.58 US Senate Office of Public Records shows that PepsiCo alone reported spending more than $9 million in 2009 to lobby the US Congress. On the basis of filings with the Federal Elections Commission, in the 2008 election cycle, the company’s Political Action Committee so-called Concerned Citizen Fund alone contributed $547 700 to candidates for federal office. Its policy emphasises contributions to candidates who are “pro-business”, and who have a “commitment to improving the business climate” pending the “candidate’s position on key com mittees where legislation of importance to PepsiCo is considered”. In another example, the Sugar Association threatened WHO that it would lobby the US Government to withdraw its funding because WHO strategy on diet, physical activity, and health highlighted a strong link between sugar and NCD risk. Several people from these industries were billed in the official agenda of the September, 2011 UN high-level meeting on NCDs as the lead representatives of civil society, and gave keynote statements designed to guide policies. One was a former US Ambassador who is now Vice President, Global Public Policy and Government Affairs, at PepsiCo. The high-level meeting civil society list also included representatives from alcohol transnationals such as Diageo, SAB Miller, and Molson Coors Brewing.

The fourth strategy is to encourage voters to oppose public health regulation. For example, the tobacco industry has, and continues to campaign for, a restricted role of government, and against taxation and regulation. Their campaigns emphasise that tobacco use is an individual responsibility and raise arguments against so-called nanny state governments. Contrastingly, public health highlights the importance of social, economic, and political factors, and ethical considerations. The differences between high-risk individual and population approaches underline the gap between public health and industry perspectives. Similarly, blame-the-victim campaigns by transnational food corporations reduce public support for govern ment interventions. As an alternative to regulatory measures, alcohol and food industries promote ineffective individually-targeted information and educational approaches, and sometimes employ counter-productive covert marketing. Their social-marketing campaigns place responsibility for the purchasing decision on the individual, and in doing so, separate these choices from the circumstances in which they are made. The media regularly emphasise personal choice and responsibility and convey government intervention as coercive and oppressive. Despite the industries’ professed faith in these information-based approaches, they avoid disclosure of relevant health information to consumers. From the denial of tobacco addiction as late as 1994 to the obstruction of traffic-light labelling of unhealthy food and the recent detraction of alcoholic drinks from EU labelling legislation, the tobacco, alcohol, and food industries have all tried to block access to objective health information and to manipulate channels of communication. To deflect criticism, corporations promote actions outside their areas of expertise. For example, tobacco corporations promote the prevention of violence against women and ultra-processed food and drink corporations emphasise physical inactivity. Tobacco and alcohol producers also highlight illegal distribution and smuggling to deter policy makers from introducing regulation that will curtail their own activity. The similarities between strategies used by the tobacco, alcohol, and food and drink corporations are unsurprising in view of the flow of people, funds, and activities across these industries, which also have histories of joint ownership—eg, Philip Morris owned both Kraft and Miller Brewing; Altria is a lead shareholder in tobacco and food companies that have shared directorships; SAB Miller Board includes at least five past or present tobacco company executives and board members; and the Diageo Executive Director, responsible for public affairs, spent 17 years in a similar role at Philip Morris. Additionally, tobacco and food and drink corporations use the same public relations firms to lobby worldwide and to design stakeholder marketing campaigns such as Pernod Ricard’s drink Responsib’All Day. The alcohol and food and drink industries are united in intense opposition to the development of an equivalent to the WHO Framework Convention on Tobacco Control. Article 5·3 of this convention outlines the protection of public health policies for tobacco control from commercial and other vested interests of the tobacco industry and is relevant to the alcohol and ultra-processed food and drink industries. The actions of transnational corporations have generated such major concerns in the public health community,that there is now an emerging willingness to address these issues with scientific methods and systematic analysis.

The case for public regulation

The precautionary principle argues against public–private partnership because there is no evidence that the partnership of alcohol and ultra-processed food and drink industries is safe or effective, unless driven by the threat of government regulation. Similarly, there is little evidence that self-regulatory approaches are effective.

We believe that civil society should be aligned with government, which has the responsibility and power to protect public health, although compromised by transnational corporations. To fulfil this aim, governments need information and support from civil society and from public health interests. Regulation, or the threat of government regulation, is the only way to change transnational corporations; therefore, the audience for public health is government and not industry. Discussions with unhealthy commodity industries will be helpful only if they are with government and if the goal is for government to use evidence-based approaches. To respond to the scale and urgency of the global NCD epidemics, the industrial drivers that underpin them, and the tactics used by the unhealthy commodity industries so far, we have ten recommendations for action:

Recommendations of action for non-communicable diseases

For public health policy making, research, and programmes:

• Unhealthy commodity industries should have no role in the formation of national or international policy for non-communicable diseases
• Interactions with the tobacco industry should be restricted and made consistent with recommendations of the Framework Convention on Tobacco Control
• Discussions with unhealthy commodity industries should be with government only and have a clear goal of the use of evidence-based approaches by government
• In the absence of robust evidence for the effectiveness of self-regulation or private–public partnership in alcohol, food, and drink industry, rigorous, timely, and
independent assessment is needed to show that they can improve health and profit

For public health professionals, institutions, and civil society:

• Highly engaged, critical action is needed to galvanise an evidence-based constituency for change to implement effective and low-cost policies, to place direct pressure on industry to change, and to raise public awareness of the unhealthy effects of these industries
• Funding and other support for research, education, and programmes should not be accepted from the tobacco, alcohol, and ultra-processed food and drinks industries or their affiliates and associates

For governments and international intergovernmental agencies:

• Evidence-based approaches such as legislation, regulation, taxation, pricing, ban, and restriction of advertising and sponsorship should be introduced to reduce death and disability from non-communicable diseases

For governments, foundations, and other funding agencies:

• All approaches in the prevention and control of non-communicable diseases — ie, self-regulation, public–private partnerships, legislation, pricing, and other regulatory measures — should be independently and objectively monitored
• Funding of policy development research into modes of regulation and market interventions should be accelerated and prioritised
• A new scientific discipline that investigates industrial diseases and the transnational corporations that drive them, should be developed.

It’s official: sugar causes diabetes. While this may seem intuitive, it has been debated for decades. Now, a new study, using data from 175 countries over the last decade, shows that sugar is an independent risk factor for diabetes. Sugar consumption explains variations in diabetes that are not explained by physical activity, overweight or obesity. The sugar-diabetes link holds true even when considering total calories, food types (including fibers, meats, fruits, oils, cereals, alcohol), and several socioeconomic variables such as aging, urbanization and income.

The level of scientific confidence here is as strong as that which linked cigarettes and lung cancer in the 1960s. Of course, we know that it took decades for the tobacco industry to actually admit the connection. Hopefully, the sugar and food industries will not be so recalcitrant.

So, what’s the size of this effect? For the every equivalent of 12 ounces of sugar-sweetened beverage introduced per person per day into a country’s food system, the rate of diabetes goes up 1 percent.

For more on the what this means for food industry and health politics, check out this article: It’s the Sugar, Folks